HEPATIC ENCEPHALOPATHY

PORTAL SYSTEMIC ENCEPHALOPATHY (PSE)

Background:

• PSE is defined as a change in mentation in a patient with cirrhosis and portal hypertension

• Cause of PSE remains contentious (? Ammonia, GABA, Mercaptans)

• CNS lesion is Astrocyte hyperplasia (Alzheimer type II astrocyte change)

Stages of Hepatic Encephalopathy

STAGE MENTAL STATUS PHYSICAL EXAM

I Euphoria/Depression, Day-Night Sleep reversal, Mild asterixis (may be absent)

poor concentration, mild confusion, slurred speech

II Increased drowsiness, confusion, inability to sustain Significant Asterixis,

Concentration Brisk reflexes

III Marked confusion, arousable but sleeping continuously Asterixis, clonus

IV Minimally responsive to painful stimuli Patient may “posture” to pain

Asterixis absent

Risk factors:

• High protein load (i.e. GI bleeding, increase in protein intake)

• SBP

• Infection

• Constipation

• Hypokalemia

• Narcotics, Benzodiazepines

• Liver failure

• Post TIPS

• Portal vein thrombosis

Treatment:

• Cure constipation (enema, Mg Citrate, MOM)

• Consider Branched chain amino acid nutritional supplements (Hepatic Aid/Nutrahep/Hepatamine)

• Lactulose 30 cc po every 1-2 hrs until soft bowel movement, titrate to achieve 2-3 soft bowel movements a day

• Neomycin 500mg po q 6

  • Use with caution in the setting of renal insufficiency

• Flagyl 500 mg po q 6

• Zinc 220 mg po tid

• L-carnitine 250 mg po tid

• Liver transplantation if refractory to therapy

• Hemodialyis (for cases with significant hyper-Ammonemia associated with Urea cycle abnormalities )

• Sodium Benzoate (for Pediatrics)

If PSE is grade III to IV, particularly in the setting of fulminant liver failure, may consider

• Bioartificial liver/extra-corporeal liver assist device (see section on Fulminant liver failure)

• Urgent liver transplantation